Sabin, Herbert NEW YORK STATE DEPARTMENT OF HEALTH
. N U ((L
Vital Records Section Burial - Transit Per it
Name First Middle Last Sex
Herbert W. Sabin Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 3, 2011 79 War or Dates Korean
ZPlace of Death Hospital, Institution or
City, Town or Village South Glens Valls Street Address 48 Fairview Extension Apt 8
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a Manner of Death )J Natural Cause I I Accident I I Homicide Suicide Undetermined Pending
1) 1/� Circumstances Investigation
us Medical Certifier Nam Title
13 fo-d' hiD
Address
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Death Certificate Filed District Number �Register Number
City, Town or Village So.Glens Falls 1
❑Burial Date / Cemetery or Crematory
❑Entombment of be Pine View Crematorium
Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address —'
H Hold
N
0 Date Point of
u) Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date I Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Sullivan-Minahan& Potter 01646
Address
407 Bay Road, Queensbury, NY 12804
- Name of Funeral Firm Making Disposition or to Whom
H, Remains are Shipped, If Other than Above
X Address
at
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Q, Permission is hereby granted to dispose of the human r ins describe bove as indicated.
Date Issued 9)(Q) IA Registrar of Vital Statistics C-ts C_
(signature)
District Number 45ay Place So.Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z W Date of Disposition et j%)it Place of Disposition I' /�
Pint 1.*TVf It,-.
W (address)
Cl)
pCZ (section) 4 (lot number (grave number)
Name of Sexton or Person in Charge of Premises isk r- e40*
Z / (please print)
iii
Signature Ali Title c 2 ES FRO&
(over)
DOH-1555(02/2004)